Thank you for your interest in the Experience VU Student Support Services Disability program!  Please complete this application as thoroughly as possible.  You cannot save and restart this application.  You may want to review the included items, take some time to make notes and gather the required documents, and then return to submit your application.  If you have any questions, please call our office at (812) 888-4061.
General Information:
Do you already have a 4-year degree? *
Are you a US Citizen, National, or Permanent Resident? *
Last Name: *
First Name: *
Middle Initial:
Preferred Name:
Preferred Pronouns:
Legal Gender:

Ethnicity/Race: Select any and all below that apply.
Race, Black or African American
Race, Asian
Race, Hawaiian or other Native to Pacific Island
Race, Hispanic
Race, American Indian or Alaskan Native

Date of Birth: *
Please ensure you have the correct year entered for the date of birth.
Address: *
Address 2:
City: *
State: *
Zip Code: *
Cell Phone:
Emergency Phone:
Email Address:

Disability Status:
Do you have a physical, hidden, or other type of documented disability?
Did you have a 504 Plan or an IEP while you were in high school?
If you have answered 'yes' to either question above regarding disability, have you provided documentation to the Office of Diverse Abilities and Accommodations at Vincennes University?
If you received any accommodations in high school, please check all that apply.
Extended Time
Distraction-free environment
Test Reader
Multiple Choice questions thrown out
One-on-one Aide

Academic Information:
Do you have any transfer credits from another university? If so, where?
Did you take any dual credit course in high school?
From what college did you receive your dual credits?
Are you a current participate of another SSS Program at another college or university?

Family Information:
Whom do you regularly reside with?
whom do you reside with if not in the list above:
Education Level of 1st Natural or Adoptive Parent
Education Level of 2nd Natural or Adoptive Parent
Income Status
Have you already filed the FAFSA?
Have you or your family experienced a significant loss of income within the last two years?
For examples: a divorce, a job loss, or a death in the family

Individual Needs Assessment (Check all that apply.)
Unsure that high school prepared me for college
Concerned about my math abilities
Concerned about my writing skills
Inexperienced with study strategies that work for me
English is a second language for me
Poor study habits
Afraid of failing in college
Undecided about whether college is for me
Do not know which majors would be a good fit for me
Have many interests but cannot seem to pick one major
Inexperienced in selecting a major or career
Not sure that I am prepared enough to succeed in my major
Not sure what type of job I can get with my degree
Plan to work over 20 hours per week and go to school
I have significant family responsibilities
It has been more than 5 years since I have been in school
I have difficulty meeting new people
I have difficulty meeting deadlines
Lack support from family and friends
I regularly commute between home and school
I will live in a residence hall on campus
I will live in campus apartments

Please describe your greatest concern(s) about attending college.

Agreement, Release, and Certificate of Truth, Accuracy, and Completeness

If accepted into the VU SSS program (i.e., COPE or Experience VU), I agree to the following:

  • I will attend the SSS program's New Student Orientation.
  • I will enroll in and complete the associated University Experience course (SSKL006).
  • I will be honest and conscientious during my meetings with SSS staff. Additional participation may be required via tutoring, workshops, cultural events, or academic enhancement.
  • I will review my midterm and final grades each semester, and discuss these grades with SSS staff.
  • I will contact the SSS main office each semester regarding advising for the next semester.
  • I will attend all classes and complete all work in a timely manner. (SSS receives notices when our students do not attend classes, miss assignments, or perform well in classes.)
  • I will contact SSS staff when I am unable to attend scheduled appointments.

I understand that I may lose my status as an SSS participant if I do not follow the terms of this agreement.

By applying to the VU TRIO SSS Program, I understand that the Program staff may obtain records or data pertinent to my eligibility and my participation from other sources. These sources may include, but not necessarily limited to, the VU Student Financial Services. the VU Bursar, the VU Registrar, the VU Office of Diverse Abilities and Accommodations, VU staff and faculty, the National Student Clearinghouse, community agencies, and other educational professional at other institutions of higher education.

I also understand that the SSS Program staff may release information to the grant funding agency of the United States government, as required by the law or the terms of the SSS grant.

Furthermore, the SSS Program professionals have my permission to communicate with VU staff and faculty, family members, community agencies, and/or off-campus professionals on my behalf. I also give my consent for the SSS program to use photos or videos taken of me by SSS staff during SSS sponsored or VU sponsored activities for SSS promotional material.

Finally, I release the SSS staff from all legal responsibility or liability that may arise from the actions that I have authorized.

I certify that I have read the terms of this agreement and release and that the information I have provided on this application is - to the best of my knowledge - true, accurate, and complete. 

Applicant Signature
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Signature: (Type in your full name)
I agree to the terms included.

Terms of Submission:

By submitting this application, you acknowledge that all of the above information is correct and accurate to the best of your understanding.